It is arranged by our practice (‘just in case’ specialty and just states the best existing evidence for an intervention order peni large 30 caps line herbs urinary tract infection. Te editors decide what questions are relevant but the book is based on what doctors need order peni large 30caps with visa herbals 24. Doctors can look up information when they need it (the ‘pull’ method of obtaining information). In the next sections we will look at some case studies where deliberately seek EBM methods were used and then ﬁnd out how to frame a question to make information to answer a it easier to answer. Ten we will learn about how to use MEDLINE and the speciﬁc question (‘just in Cochrane databases to electronically search for the information we need and, time’ learning). You can then think of your own clinical question which you would like to answer at the workshop. Case study 1: persistent cough A 58-year-old who was visiting her GP about another matter, said, as an aside: ‘Can you do anything about a cough? Te GP searched PubMed (the web-based version of MEDLINE) using ‘Clinical Queries’, which is a category of PubMed designed for clinicians (see pages 52–54). Te search for persistent cough revealed that the most common causes of a persistent cough are: • postnasal drip • asthma • chronic bronchitis Te GP thought the cough was most likely to be due to asthma, and prescribed appropriate treatment for asthma as a ﬁrst line of treatment. Te patient thought she had already tried that treatment and that it did not work but tried it again anyway, without success. However, the search also showed that gastro-oesophageal reﬂux is a less common but possible cause of persistent cough (10% of cases), which the GP had not known before. Te GP therefore recommended the patient to take antacids at night and raise the head of her bed. After one week her cough disappeared for the ﬁrst time in 20 years and has not come back since. It was written up in the British Medical Journal and published as an example of how EBM can help GPs. However, some physicians wrote in saying that ‘everyone should know’ that gastro-oesophageal reﬂux was a possible cause of cough. Te author replied that although respiratory physicians might know this information, GPs did not necessarily know it. An anaesthetist wrote in to say Reference: that after reading the article he had been treated for gastro-oesophageal reﬂux, which had cured a cough he had had for 30 years! Evidence based case report: Twenty year cough Conclusion: EBM can help you ﬁnd the information you need, whether or not in a non-smoker. It looked clean and the outcomes GP and patient wondered whether it was necessary to give prophylactic antibiotics. She searched MEDLINE and found a meta-analysis indicating that Outcomes are commonly the average infection rate for dog bites was 14% and that antibiotics halved this measured as absolute risk risk. In other words: reduction (ARR), relative risks (RR) and number needed to • for every 100 people with dog bites, treatment with antibiotics will save 7 treat (NNT). Te GP explained these ﬁgures to the patient, along with the possible Te risk of infection after dog consequences of an infection, and the patient decided not to take antibiotics. As the culture (Tat is, 7 people in every 100 of health care changes further towards consumer participation in health care treated will be saved from infection. Antibiotics to prevent infection in patients with dog bite wounds: a meta- (Tat is, you would need to analysis of randomized trials. RR is harder to put into context because it is independent of the frequency of the problem (the ‘event rate’), in this case, the rate at which people with dog bites get infected. Further information on these measures is given in EBM Step 4 (Rapid critical appraisal). Te students accurately found microscopic traces of blood in 10,000 men were screened. It was time for a search of the literature for asked to visit their GP and evidence of the eﬀectiveness of these procedures. Of these: He searched for a cohort study of 40–50-year-olds with haematuria with long- term follow-up and for RCTs of screening for haematuria. He used the search • 2 had bladder cancer categories ‘prognosis’ and ‘speciﬁcity’ and the search terms ‘haematuria OR • 1 had reﬂux nephropathy.

Drop attacks may occur while walking peni large 30 caps cheap herbals stores, while have attempted to identify the "most likely cause of indi- turning the neck peni large 30 caps herbals india chennai, while looking up, or without an obvious vidual falls," falling among nursing home residents, as precipitating movement. Some individuals note that their among community-living residents, most often results knees buckled or "just gave out. The prevalence of the impairments is higher etiology and frequency of drop attacks are unknown. Similar to community studies, studies of nursing obvious intrinsic or environmental cause is reported in home residents have identiﬁed an increased risk of falling less than 5% of falls. Only a small percentage of falls occur during clearly hazardous activ- Host factors such as acute illness, postural hypotension, ities such as climbing on chairs or ladders or participat- dizziness, or medications have been described. Also, by ascertain because studies lack control data on nonfallers and large, institutions are safer environments than the or fallers at times other than their fall. Nutrition 1011 be life threatening, warrant hospitalization, and necessi- uration, is frequently misdiagnosed as iron-deﬁciency tate a prolonged period of recuperation. This error results in the inappro- For these, aggressive attempts at assuring adequate priate administration of oral iron therapy and unneces- hydration are essential in the elderly. Furthermore, this sary invasive investigative procedures to identify the must commence soon after the development of a minor source of iron loss. Patients and their families ciated with an impaired ability of the reticuloendothelial must be educated to emphasize the importance of main- system to recirculate iron obtained from the breakdown taining adequate ﬂuid intake at all times and to carefully of phagocytosed senescent red cells. Thus, in the anemia monitor intake if a minor illness develops or if ﬂuid of chronic disease, iron stores are normal or increased, requirements are increased, as occurs during heat waves. In the hospitalized older patient, the possibility that con- Recent studies indicate a correlation between in- fusion or delirium is caused by dehydration should be creased iron stores and risks of neoplasia and coronary high on the differential diagnosis list. Because aging is associated with increas- assure that their patients have adequate access to water. Consuming a multivitamin monitored by frequent weight and intake and output with minerals containing the RDA for iron, combined measurements. If current evidence conﬁrms adverse effects of iron stores, the use of iron-containing supplements in the elderly may well be unwise. Numerous studies indicate that, for a wide variety of min- erals and vitamins, intake is signiﬁcantly lower than the RDA for a large proportion of ambulatory elderly. The mineral may be involved in minimizing free Of most importance is the evidence that lifelong inade- radical accumulation, as it is essential for the normal quate intakes of calcium contribute to the high prev- function of glutathione peroxidase. It is generally deﬁciency has been reported frequently in the elderly, recommended that calcium intake in the elderly be although syndromes associated with selenium deﬁciency between 1. There is some evidence that selenium deﬁ- ciency may contribute to a greater neoplastic risk and The prevalence of zinc deﬁciency is important because of declines in immune function. In elderly subjects with chronic debilitat- ing diseases, modest zinc deﬁciency may contribute to Aging generally is associated with increases in serum anorexia. Although not clinically proven, there is also evi- copper concentrations, although the signiﬁcance of this dence that zinc supplementation aids in wound healing increase is unknown. Copper deﬁciency is very rare and in general and in the healing of pressure ulcers in par- has been reported only in total parenteral nutrition. Recent evidence has suggested an important role for chromium in carbohydrate metabolism. It In younger patients, iron deﬁciency is the most common is possible that chromium deﬁciency may contribute to cause of anemia and the most common global deﬁciency glucose intolerance in the elderly, although the thera- leading to widespread morbidity and decreased work peutic efﬁcacy of chromium replacement is controversial. As a consequence, iron deﬁciency is rare in the elderly and invariably is caused by pathologic blood loss. It is important to empha- Studies have shown that dietary intake of many vitamins size that the anemia of chronic disease, which is associ- is inadequate in the elderly, including an intake of 50% ated with iron-deﬁcient erythropoiesis, including a low or less for folic acid, thiamine, vitamin D, and vitamin E. Providing supplements such as drug use (digoxin, ﬂuoxytene), thyrotoxicosis, with meals is not recommended, as total caloric intake and depression can usually result in weight gain if the will not be improved. The importance of a comprehen- underlying condition is corrected with appropriate sive rehabilitation program cannot be overemphasized. Other conditions that may well Recent evidence has shown that increased caloric intake contribute to weight loss that are potentially improvable can only be achieved when nutritional supplementation include social or economic isolation, difﬁculties with is accompanied by an aggressive and proactive program 10 cooking or feeding as a consequence of physical disabil- of exercise and physical therapy (Fig. Patients ity, dental or swallowing problems, and not provid- who fail to respond to treatment of their underlying ing palatable or preferred foods. Failure to identify a medical condition and fail to gain weight despite nutri- cause for weight loss is generally accompanied by a poor tional and physical rehabilitation carry a very poor prognosis despite aggressive medical and nutritional prognosis. Older persons who have experienced weight loss are consuming inadequate calories to meet their needs.

Musculoskeletal examination buy cheap peni large 30caps online herbals detox, often a source of abun- Cardiac examination has several special features in dant complaints and pathology in older adults purchase 30 caps peni large with visa herbals 2, begins aged patients. In the absence of complaints or common at baseline without symptoms or ominous prog- loss of function, brief tests of function are adequate to nosis. For upper extremity, 4 free of cardiac disease, S3 is associated with congestive "Touch the back of your head with your hands" and "Pick heart failure. The ubiquitous systolic ejection murmur is up the spoon" are sensitive and speciﬁc. A loud murmur from a chair, walk 3 m, turn, walk back, and sit down); (>2/6), diminution of the aortic component of S2, nar- requiring that each foot be off the ﬂoor in the "up and rowed pulse pressure, and dampening of the carotid go" yields a test that is a better predictor of functional upstroke suggest aortic stenosis, but each may be absent deﬁcits than standard detailed neuromuscular examina- and be falsely reassuring. Although for decades aortic sclerosis was con- or itching or dyspareunia, is remarkably easy and grati- sidered benign, it has recently been associated with fying to treat. Topical (often difﬁcult for the elderly increased risk for myocardial infarction, congestive woman with arthritis to manage) or oral conjugated heart failure, stroke, and death from cardiovascular estrogen may often be discontinued after a few weeks causes, even without evidence of signiﬁcant outﬂow without return of symptoms. Unsuspected a woman over 50 years is considered malignant until fecal impaction is common and, despite no complaint of proven otherwise. Evidence of fecal a table with the patient positioned on her side with knees or urinary incontinence is usually obvious to the alert drawn up will allow speculum exam and Papanicolau examiner. The bimanual exam can be done with the patient der should be suspected in men who are incontinent. Signs of abuse may Although part of the screen for prostate cancer, prosta- only be apparent on pelvic examination. Abnormalities are thought to be benign causes outnumber malignant ones; differentiation common and their clinical importance is sometimes by imaging is thought not to be reliable unless calciﬁca- uncertain, because of either lack of data or existence tion is present. Odenheimer117 has approached the plasia (because cell proliferation occurs, hypertrophy is problem rationally; in an age-stratiﬁed (65–74, 75–84, an incorrect term) correlates poorly with both urethral >85) random sample of nearly 500 community-dwelling obstruction and symptoms of prostatism; anterior peri- older persons, comprehensive physical, psychiatric, neu- urethral encroachment causes symptoms, but it is the pos- ropsychologic, and neurologic examinations were per- terolateral portions of the gland that are accessible on formed. Clinical Approach to the Older Patient 159 determine whether neurologic abnormalities could be particularly helpful in assessing the severity and func- attributed to identiﬁable disease or existed in the absence tional importance of peripheral neuropathy. The logic examination of the older patient, one-third to one- precise prevalence of peripheral neuropathy in elderly half the abnormal ﬁndings have no identiﬁable disease persons is yet unknown (estimates vary from 10% in the causing them. Abnormalities were classiﬁed as (a) attrib- nondiabetic population to around 50% among diabetic utable to a disease or an isolated abnormality; and (b) patients older than 60 years), but the presence of disease, more common with increasing age or not. Abnor- References malities attributable to disease and more common with increasing age simply reﬂect diseases that are more 1. Illness behavior in common in older persons and have nervous system ﬁnd- the aged, implications for clinicians. New York: Free age are most likely individual variations not attributable Press; 1978. Health and illness progression occurs following changes that developed behaviors in elder veterans. Analysis of previous reports of abnormal neurologic Cambridge: Harvard University Press; 1984. Differences in the Most studies include subjects screened inadequately or appraisal of health between aged and middle-aged adults. On the other hand, the consid- vival of a cohort of very old Canadians: results from the erable prevalence of neurologic abnormalities in older second wave of the Canadian Study of Health and Aging. For health in persons aged 85 and over: results from the example, frontal release signs (also called "primitive" Canadian Study of Health and Aging. Can J Public Health reﬂexes)—snout, palmomental, root, suck, grasp, glabel- 1996;87(1):28–31. The Prevention of Illness in the Elderly:The dementia118–120 or with Parkinson’s disease. Proceed- ings of a conference held at the Royal College of Physi- signs appear in 10% to 35% of older adults screened to 117,121,122 cians of London. Old people at home: these signs as identiﬁers of disease, at least in older their unreported needs.

Self-help in relation to swallowing It is possible to give general guidelines as to what you can do yourself to help swallowing buy 30 caps peni large fast delivery herbalsondemandcom, although it must be remembered each person has slightly different problems order 30 caps peni large with amex lotus herbals 3 in 1 review, and thus not every strategy will work for everyone. However, things to try yourself include: • changing the type and preparation of your food – solid foods, particularly those that are only half chewed, are much more difﬁcult to swallow than those which are softer, so you may need to consider chopping or blending food; • changing the ways in which you eat and swallow – eating little and often may help; • exercising to strengthen the relevant muscles as much as possible; • making sure that you do not talk (or laugh) and eat at the same EATING AND SWALLOWING DIFFICULTIES; DIET AND NUTRITION 131 time – problems of swallowing can often be linked to trying to do two things at once! In MS, coordination of the swallowing reﬂex with the amount of saliva you have may become a problem. It is not that you are producing more saliva, but the swallowing of it becomes far more noticeable. In general you have to become more conscious of the process of swallowing, and try and systematically swallow. Indeed swallowing exercises may help you and, paradoxically, by stimulating more regular production of salivation through sucking a sweet (preferably sugar free! A problem often arises when you ‘forget’ to swallow for a period of time and then suddenly notice the saliva. You might try a sequence of events as you eat or drink a little at a time, based on the following: ‘Hold your breath, swallow, clear your throat, then swallow again. Some people still have great difﬁculty but, if food or drink gets into your lungs, which could possibly lead to pneumonia, then more drastic action may be required. The time being taken to eat and drink may also be now so substantial that you run the risk of not getting adequate nutrition or liquids over a period of time. If this happens, then you may ﬁnd yourself losing weight, getting weaker and having further problems. It is an important decision to move from normal feeding by mouth (oral feeding and drinking) to non-oral feeding, where food is directly channelled into the stomach (often avoiding the mouth and swallowing completely), but this step may be necessary if problems with nutrition and/or concern over choking becomes substantial. For example, after certain kinds of surgery in hospital, not associated with MS, people may be fed on a short-term basis through a tube that passes through the nose and then through the throat directly to the stomach (a ‘nasogastric tube’). This particular kind of arrangement has to be temporary because the throat and nose may become irritated after a while. A more long-term arrangement is to have a PEG (‘percutaneous endoscopic gastrostomy’) in which a tube is inserted through the abdominal wall directly into the stomach. As with any surgical openings through the skin, hygiene is particularly important, and great care has to be taken to prevent infections arising. Although it is a particularly difﬁcult step to move to non-oral feeding, for social reasons as well as because of the loss of the pleasures associated with normal eating and drinking, in some cases it may be the best decision, in order to build up your strength if you have been losing a lot of weight, and to prevent fears associated with choking. If you are very careful, it may also be possible to continue to eat or drink a few things orally, at least to retain some of the pleasures of eating normally. You should keep an eye on how your swallowing goes, and always consult with your professional advisors about the possibility of gradually changing the balance between oral and non-oral feeding, so that you can try and resume a greater proportion of oral feeding, with a view to removing the PEG method of feeding if you can. Diet and nutrition There are two broad ways in which diet and nutrition can be considered in relation to MS. The ﬁrst and less contentious relates to your general health: ideas about what is a good diet for general health do, of course, change from time to time. The second deals with the possible beneﬁcial or harmful effects that some diets themselves might have on either symptoms or, more fundamentally, on the underlying cause of the MS. Diet is the most obvious and easy to implement factor that could be changed by people with MS, and many people have focused on this issue. Also, health care professionals are often very interested in diet and its effects on all aspects of general health. Although there has been research on diet and MS, it has not been a core interest of most EATING AND SWALLOWING DIFFICULTIES; DIET AND NUTRITION 133 researchers because Western populations are largely well-nourished – obesity and overeating, on the contrary, are major health concerns. There have been many diets that have been suggested to affect either speciﬁc symptoms or the cause of MS. There is little evidence that any of these diets has the effects that their supporters suggest – however, we here discuss a number of the more plausible diets. Essential fatty acids One of the areas of nutrition that has been researched in relation to MS has been that of ‘essential fatty acids’, which form part of the building blocks of the brain and nervous system tissue, and are essential to the development and maintenance of the CNS. Actually essential fatty acid is rather an odd phrase in lay terms, for we are used to thinking of anything ‘fatty’ as very bad for you.

American College of Sports Medicine (ACSM) (1998) The recommended quantity and quality of exercise for developing and maintaining cardiorespiratory and muscular ﬁtness purchase 30 caps peni large sriram herbals, and ﬂexibility in healthy adults buy peni large 30 caps otc herbal. American College of Sports Medicine (ACSM) (2001) Resource Manual for Guidelines for Exercise Testing and Prescription, 4th edn, Williams and Wilkins, London. American Council on Exercise (ACE) (1998) Exercise for Older Adults, Human Kinet- ics, Champaign, IL. American Heart Association (AHA) (1995) Exercise standards:A statement for health care professionals. Association of Chartered Physiotherapists in Cardiac Rehabilitation (ACPICR) (1999) The Chartered Society of Physiotherapy. Standards for the exercise component of Phase III Cardiac Rehabilitation,The Chartered Society of Physiotherapy, London. Association of Chartered Physiotherapists in Cardiac Rehabilitation (ACPICR) (2003) Exercise Physiology and its Application to Exercise Prescription in Cardiac Rehabil- itation – course manual. Recommendations of the German Federation for Cardiovascular Prevention and Rehabilitation. British Association for Cardiac Rehabilitation (BACR) (1995) BACR Guidelines for Cardiac Rehabilitation, Blackwell Science, Oxford. British Association for Cardiac Rehabilitation (BACR) (2000) Cardiac Rehabilitation: An Educational Resource. British Heart Foundation (BHF) (2001) Coronary Angioplasty and Coronary Bypass Surgery, British Heart Foundation, London. British Heart Foundation (BHF) (2002) Heart Attack and Rehabilitation, British Heart Foundation, London. Scottish Intercollegiate Guidelines Network (SIGN) (2002) Cardiac Rehabilitation,no. Chapter 5 Class Design and Use of Music in Cardiac Rehabilitation Linda Harley and Gillian Armstrong Chapter outline This chapter focuses on the practical aspects of exercise delivery for phases III and IV group-based exercise classes. Different methods and styles of arranging the group within a space are given to provide interest and variety for the class. In addition, integrating information from previous sections, this chapter explores practical methods for individualising and ideas for progress- ing exercise prescription. Designing an exercise class requires a good working knowledge of the various physiological responses to exercise and monitoring skills discussed in previous chapters. The components of warm-up (with pulse- raiser, mobility exercises and preparatory stretch), followed by a conditioning component and ﬁnally a cool-down incorporating pulse-lowering and devel- opmental stretches are described in order. The use of musculoskeletal endurance exercises as a form of active recovery is discussed. A well-planned and properly executed warm-up improves exercise performance and max- imises both the safety and effectiveness of the exercise session. Warm-ups should be at least 15 minutes’ duration for cardiac rehabilitation (SIGN, 2002; ACPICR, 2003). This extended time prepares the cardiovascular system for the activity that follows. With this slow, gradual progression of effort, coronary circulation is enhanced (through vasodilation of the coronary arteries), thus Exercise Leadership in Cardiac Rehabilitation. ISBN 0-470-01971-9 Chapter 5 Class Design and Use of Music in Cardiac Rehabilitation Linda Harley and Gillian Armstrong Chapter outline This chapter focuses on the practical aspects of exercise delivery for phases III and IV group-based exercise classes. Different methods and styles of arranging the group within a space are given to provide interest and variety for the class. In addition, integrating information from previous sections, this chapter explores practical methods for individualising and ideas for progress- ing exercise prescription. Designing an exercise class requires a good working knowledge of the various physiological responses to exercise and monitoring skills discussed in previous chapters. The components of warm-up (with pulse- raiser, mobility exercises and preparatory stretch), followed by a conditioning component and ﬁnally a cool-down incorporating pulse-lowering and devel- opmental stretches are described in order. The use of musculoskeletal endurance exercises as a form of active recovery is discussed. A well-planned and properly executed warm-up improves exercise performance and max- imises both the safety and effectiveness of the exercise session. Warm-ups should be at least 15 minutes’ duration for cardiac rehabilitation (SIGN, 2002; ACPICR, 2003).